Systems and methods for medical stapling

ABSTRACT

Certain aspects relate to systems and techniques for articulating medical instruments. In one aspect, the instrument includes a wrist having at least two degrees of freedom of movement, and an end effector coupled to the wrist. The end effector can include an upper jaw, a lower jaw, and a firing mechanism configured to form staples in tissue. Actuation of the firing mechanism can be decoupled from the movement of the wrist in the at least two degrees of freedom.

CROSS-REFERENCE TO RELATED APPLICATION(S)

This application claims the benefit of U.S. Provisional Application No. 62/823,285, filed Mar. 25, 2019, which is hereby incorporated by reference in its entirety.

TECHNICAL FIELD

The systems and methods disclosed herein are directed to medical instruments, and more particularly to medical staplers including an articulating wrist.

BACKGROUND

Medical staplers can be used in a variety of different medical procedures, including, for example, laparoscopic procedures in which the medical stapler may be used to transect and/or seal tissue. Medical staplers can include two jaws configured to clamp tissue therebetween and then transect and seal the tissue clamped between the two jaws. When used as part of a robotic system, it can be desirable to provide one or more of degrees of freedom (DOF) of movement at an articulating wrist of the medical stapler.

SUMMARY

The systems, methods and devices of this disclosure each have several innovative aspects, no single one of which is solely responsible for the desirable attributes disclosed herein.

In one aspect, there is provided an instrument, comprising: a wrist having at least two degrees of freedom of movement; and an end effector coupled to the wrist, the end effector comprising an upper jaw, a lower jaw, and a firing mechanism configured to form staples in tissue, wherein actuation of the firing mechanism is decoupled from the movement of the wrist in the at least two degrees of freedom.

In another aspect, there is provided an instrument, comprising: a wrist; an end effector coupled to the wrist, the end effector comprising an upper jaw, a lower jaw, and a firing mechanism configured to form staples in tissue; and a pair of push shafts configured to drive actuation of the firing mechanism.

In yet another aspect, there is provided an instrument, comprising: a wrist having at least two degrees of freedom of movement; and an end effector coupled to the wrist, the end effector comprising an upper jaw and a lower jaw, the end effector configured to be removably coupled with a cartridge.

BRIEF DESCRIPTION OF THE DRAWINGS

The disclosed aspects will hereinafter be described in conjunction with the appended drawings, provided to illustrate and not to limit the disclosed aspects, wherein like designations denote like elements.

FIG. 1 illustrates an embodiment of a cart-based robotic system arranged for diagnostic and/or therapeutic bronchoscopy procedure(s).

FIG. 2 depicts further aspects of the robotic system of FIG. 1 .

FIG. 3 illustrates an embodiment of the robotic system of FIG. 1 arranged for ureteroscopy.

FIG. 4 illustrates an embodiment of the robotic system of FIG. 1 arranged for a vascular procedure.

FIG. 5 illustrates an embodiment of a table-based robotic system arranged for a bronchoscopy procedure.

FIG. 6 provides an alternative view of the robotic system of FIG. 5 .

FIG. 7 illustrates an example system configured to stow robotic arm(s).

FIG. 8 illustrates an embodiment of a table-based robotic system configured for a ureteroscopy procedure.

FIG. 9 illustrates an embodiment of a table-based robotic system configured for a laparoscopic procedure.

FIG. 10 illustrates an embodiment of the table-based robotic system of FIGS. 5-9 with pitch or tilt adjustment.

FIG. 11 provides a detailed illustration of the interface between the table and the column of the table-based robotic system of FIGS. 5-10 .

FIG. 12 illustrates an alternative embodiment of a table-based robotic system.

FIG. 13 illustrates an end view of the table-based robotic system of FIG. 12 .

FIG. 14 illustrates an end view of a table-based robotic system with robotic arms attached thereto.

FIG. 15 illustrates an exemplary instrument driver.

FIG. 16 illustrates an exemplary medical instrument with a paired instrument driver.

FIG. 17 illustrates an alternative design for an instrument driver and instrument where the axes of the drive units are parallel to the axis of the elongated shaft of the instrument.

FIG. 18 illustrates an instrument having an instrument-based insertion architecture.

FIG. 19 illustrates an exemplary controller.

FIG. 20 depicts a block diagram illustrating a localization system that estimates a location of one or more elements of the robotic systems of FIGS. 1-10 , such as the location of the instrument of FIGS. 16-18 , in accordance to an example embodiment.

FIG. 21 illustrates an example embodiment of a medical instrument in accordance with aspects of this disclosure.

FIGS. 22A and FIB. 22B illustrate an example embodiment wherein the end effector is configured to function as a medical stapler in accordance with aspects of this disclosure.

FIGS. 23A and 23B illustrates an example embodiment of a cable-driven medical instrument including an articulating wrist in accordance with aspects of this disclosure.

FIG. 24 illustrates a close up view of the lower jaw of FIGS. 23A and 23B including a portion of the internal components of the tab in accordance with aspects of this disclosure.

FIG. 25 illustrates another example embodiment of a cable-driven medical instrument including an articulating wrist in accordance with aspects of this disclosure.

FIG. 26 illustrates yet another example embodiment of a cable-driven medical instrument including an articulating wrist in accordance with aspects of this disclosure.

FIG. 27 illustrates still yet another example embodiment of a cable-driven medical instrument including an articulating wrist in accordance with aspects of this disclosure.

FIGS. 28 and 29 illustrate a top-down view and an endpoint view of yet another example embodiment of a cable-driven medical instrument including an articulating wrist in accordance with aspects of this disclosure.

FIG. 30 illustrates an example embodiment of a push shaft-driven medical instrument including an articulating wrist in accordance with aspects of this disclosure.

FIG. 31 provides a view of the cartridge of FIG. 30 , separated from the instrument in accordance with aspects of this disclosure.

FIG. 32 illustrates another view of the push shaft-driven medical instrument of FIG. 30 in accordance with aspects of this disclosure.

FIG. 33 illustrates yet another view of the push shaft-driven medical instrument of FIG. 30 from the bottom in accordance with aspects of this disclosure.

FIG. 34 illustrates yet another view of the push shaft-driven medical instrument of FIG. 30 without the cartridge installed in accordance with aspects of this disclosure.

FIGS. 35A-35D provide a plurality of views of a tab which can be included in the firing mechanism of the push shaft-driven medical instrument in accordance with aspects of this disclosure.

DETAILED DESCRIPTION 1. Overview

Aspects of the present disclosure may be integrated into a robotically-enabled medical system capable of performing a variety of medical procedures, including both minimally invasive, such as laparoscopy, and non-invasive, such as endoscopy, procedures. Among endoscopy procedures, the system may be capable of performing bronchoscopy, ureteroscopy, gastroscopy, etc.

In addition to performing the breadth of procedures, the system may provide additional benefits, such as enhanced imaging and guidance to assist the physician. Additionally, the system may provide the physician with the ability to perform the procedure from an ergonomic position without the need for awkward arm motions and positions. Still further, the system may provide the physician with the ability to perform the procedure with improved ease of use such that one or more of the instruments of the system can be controlled by a single user.

Various embodiments will be described below in conjunction with the drawings for purposes of illustration. It should be appreciated that many other implementations of the disclosed concepts are possible, and various advantages can be achieved with the disclosed implementations. Headings are included herein for reference and to aid in locating various sections. These headings are not intended to limit the scope of the concepts described with respect thereto. Such concepts may have applicability throughout the entire specification.

A. Robotic System—Cart.

The robotically-enabled medical system may be configured in a variety of ways depending on the particular procedure. FIG. 1 illustrates an embodiment of a cart-based robotically-enabled system 10 arranged for a diagnostic and/or therapeutic bronchoscopy procedure. During a bronchoscopy, the system 10 may comprise a cart 11 having one or more robotic arms 12 to deliver a medical instrument, such as a steerable endoscope 13, which may be a procedure-specific bronchoscope for bronchoscopy, to a natural orifice access point (i.e., the mouth of the patient positioned on a table in the present example) to deliver diagnostic and/or therapeutic tools. As shown, the cart 11 may be positioned proximate to the patient's upper torso in order to provide access to the access point. Similarly, the robotic arms 12 may be actuated to position the bronchoscope relative to the access point. The arrangement in FIG. 1 may also be utilized when performing a gastro-intestinal (GI) procedure with a gastroscope, a specialized endoscope for GI procedures. FIG. 2 depicts an example embodiment of the cart in greater detail.

With continued reference to FIG. 1 , once the cart 11 is properly positioned, the robotic arms 12 may insert the steerable endoscope 13 into the patient robotically, manually, or a combination thereof. As shown, the steerable endoscope 13 may comprise at least two telescoping parts, such as an inner leader portion and an outer sheath portion, each portion coupled to a separate instrument driver from the set of instrument drivers 28, each instrument driver coupled to the distal end of an individual robotic arm. This linear arrangement of the instrument drivers 28, which facilitates coaxially aligning the leader portion with the sheath portion, creates a “virtual rail” 29 that may be repositioned in space by manipulating the one or more robotic arms 12 into different angles and/or positions. The virtual rails described herein are depicted in the Figures using dashed lines, and accordingly the dashed lines do not depict any physical structure of the system. Translation of the instrument drivers 28 along the virtual rail 29 telescopes the inner leader portion relative to the outer sheath portion or advances or retracts the endoscope 13 from the patient. The angle of the virtual rail 29 may be adjusted, translated, and pivoted based on clinical application or physician preference. For example, in bronchoscopy, the angle and position of the virtual rail 29 as shown represents a compromise between providing physician access to the endoscope 13 while minimizing friction that results from bending the endoscope 13 into the patient's mouth.

The endoscope 13 may be directed down the patient's trachea and lungs after insertion using precise commands from the robotic system until reaching the target destination or operative site. In order to enhance navigation through the patient's lung network and/or reach the desired target, the endoscope 13 may be manipulated to telescopically extend the inner leader portion from the outer sheath portion to obtain enhanced articulation and greater bend radius. The use of separate instrument drivers 28 also allows the leader portion and sheath portion to be driven independent of each other.

For example, the endoscope 13 may be directed to deliver a biopsy needle to a target, such as, for example, a lesion or nodule within the lungs of a patient. The needle may be deployed down a working channel that runs the length of the endoscope to obtain a tissue sample to be analyzed by a pathologist. Depending on the pathology results, additional tools may be deployed down the working channel of the endoscope for additional biopsies. After identifying a nodule to be malignant, the endoscope 13 may endoscopically deliver tools to resect the potentially cancerous tissue. In some instances, diagnostic and therapeutic treatments can be delivered in separate procedures. In those circumstances, the endoscope 13 may also be used to deliver a fiducial to “mark” the location of the target nodule as well. In other instances, diagnostic and therapeutic treatments may be delivered during the same procedure.

The system 10 may also include a movable tower 30, which may be connected via support cables to the cart 11 to provide support for controls, electronics, fluidics, optics, sensors, and/or power to the cart 11. Placing such functionality in the tower 30 allows for a smaller form factor cart 11 that may be more easily adjusted and/or repositioned by an operating physician and his/her staff. Additionally, the division of functionality between the cart/table and the support tower 30 reduces operating room clutter and facilitates improving clinical workflow. While the cart 11 may be positioned close to the patient, the tower 30 may be stowed in a remote location to stay out of the way during a procedure.

In support of the robotic systems described above, the tower 30 may include component(s) of a computer-based control system that stores computer program instructions, for example, within a non-transitory computer-readable storage medium such as a persistent magnetic storage drive, solid state drive, etc. The execution of those instructions, whether the execution occurs in the tower 30 or the cart 11, may control the entire system or sub-system(s) thereof. For example, when executed by a processor of the computer system, the instructions may cause the components of the robotics system to actuate the relevant carriages and arm mounts, actuate the robotics arms, and control the medical instruments. For example, in response to receiving the control signal, the motors in the joints of the robotics arms may position the arms into a certain posture.

The tower 30 may also include a pump, flow meter, valve control, and/or fluid access in order to provide controlled irrigation and aspiration capabilities to the system that may be deployed through the endoscope 13. These components may also be controlled using the computer system of tower 30. In some embodiments, irrigation and aspiration capabilities may be delivered directly to the endoscope 13 through separate cable(s).

The tower 30 may include a voltage and surge protector designed to provide filtered and protected electrical power to the cart 11, thereby avoiding placement of a power transformer and other auxiliary power components in the cart 11, resulting in a smaller, more moveable cart 11.

The tower 30 may also include support equipment for the sensors deployed throughout the robotic system 10. For example, the tower 30 may include opto-electronics equipment for detecting, receiving, and processing data received from the optical sensors or cameras throughout the robotic system 10. In combination with the control system, such opto-electronics equipment may be used to generate real-time images for display in any number of consoles deployed throughout the system, including in the tower 30. Similarly, the tower 30 may also include an electronic subsystem for receiving and processing signals received from deployed electromagnetic (EM) sensors. The tower 30 may also be used to house and position an EM field generator for detection by EM sensors in or on the medical instrument.

The tower 30 may also include a console 31 in addition to other consoles available in the rest of the system, e.g., console mounted on top of the cart. The console 31 may include a user interface and a display screen, such as a touchscreen, for the physician operator. Consoles in system 10 are generally designed to provide both robotic controls as well as pre-operative and real-time information of the procedure, such as navigational and localization information of the endoscope 13. When the console 31 is not the only console available to the physician, it may be used by a second operator, such as a nurse, to monitor the health or vitals of the patient and the operation of system, as well as provide procedure-specific data, such as navigational and localization information. In other embodiments, the console 30 is housed in a body that is separate from the tower 30.

The tower 30 may be coupled to the cart 11 and endoscope 13 through one or more cables or connections (not shown). In some embodiments, the support functionality from the tower 30 may be provided through a single cable to the cart 11, simplifying and de-cluttering the operating room. In other embodiments, specific functionality may be coupled in separate cabling and connections. For example, while power may be provided through a single power cable to the cart, the support for controls, optics, fluidics, and/or navigation may be provided through a separate cable.

FIG. 2 provides a detailed illustration of an embodiment of the cart from the cart-based robotically-enabled system shown in FIG. 1 . The cart 11 generally includes an elongated support structure 14 (often referred to as a “column”), a cart base 15, and a console 16 at the top of the column 14. The column 14 may include one or more carriages, such as a carriage 17 (alternatively “arm support”) for supporting the deployment of one or more robotic arms 12 (three shown in FIG. 2 ). The carriage 17 may include individually configurable arm mounts that rotate along a perpendicular axis to adjust the base of the robotic arms 12 for better positioning relative to the patient. The carriage 17 also includes a carriage interface 19 that allows the carriage 17 to vertically translate along the column 14.

The carriage interface 19 is connected to the column 14 through slots, such as slot 20, that are positioned on opposite sides of the column 14 to guide the vertical translation of the carriage 17. The slot 20 contains a vertical translation interface to position and hold the carriage at various vertical heights relative to the cart base 15. Vertical translation of the carriage 17 allows the cart 11 to adjust the reach of the robotic arms 12 to meet a variety of table heights, patient sizes, and physician preferences. Similarly, the individually configurable arm mounts on the carriage 17 allow the robotic arm base 21 of robotic arms 12 to be angled in a variety of configurations.

In some embodiments, the slot 20 may be supplemented with slot covers that are flush and parallel to the slot surface to prevent dirt and fluid ingress into the internal chambers of the column 14 and the vertical translation interface as the carriage 17 vertically translates. The slot covers may be deployed through pairs of spring spools positioned near the vertical top and bottom of the slot 20. The covers are coiled within the spools until deployed to extend and retract from their coiled state as the carriage 17 vertically translates up and down. The spring-loading of the spools provides force to retract the cover into a spool when carriage 17 translates towards the spool, while also maintaining a tight seal when the carriage 17 translates away from the spool. The covers may be connected to the carriage 17 using, for example, brackets in the carriage interface 19 to ensure proper extension and retraction of the cover as the carriage 17 translates.

The column 14 may internally comprise mechanisms, such as gears and motors, that are designed to use a vertically aligned lead screw to translate the carriage 17 in a mechanized fashion in response to control signals generated in response to user inputs, e.g., inputs from the console 16.

The robotic arms 12 may generally comprise robotic arm bases 21 and end effectors 22, separated by a series of linkages 23 that are connected by a series of joints 24, each joint comprising an independent actuator, each actuator comprising an independently controllable motor. Each independently controllable joint represents an independent degree of freedom available to the robotic arm. Each of the arms 12 have seven joints, and thus provide seven degrees of freedom. A multitude of joints result in a multitude of degrees of freedom, allowing for “redundant” degrees of freedom. Redundant degrees of freedom allow the robotic arms 12 to position their respective end effectors 22 at a specific position, orientation, and trajectory in space using different linkage positions and joint angles. This allows for the system to position and direct a medical instrument from a desired point in space while allowing the physician to move the arm joints into a clinically advantageous position away from the patient to create greater access, while avoiding arm collisions.

The cart base 15 balances the weight of the column 14, carriage 17, and arms 12 over the floor. Accordingly, the cart base 15 houses heavier components, such as electronics, motors, power supply, as well as components that either enable movement and/or immobilize the cart. For example, the cart base 15 includes rollable wheel-shaped casters 25 that allow for the cart to easily move around the room prior to a procedure. After reaching the appropriate position, the casters 25 may be immobilized using wheel locks to hold the cart 11 in place during the procedure.

Positioned at the vertical end of column 14, the console 16 allows for both a user interface for receiving user input and a display screen (or a dual-purpose device such as, for example, a touchscreen 26) to provide the physician user with both pre-operative and intra-operative data. Potential pre-operative data on the touchscreen 26 may include pre-operative plans, navigation and mapping data derived from pre-operative computerized tomography (CT) scans, and/or notes from pre-operative patient interviews. Intra-operative data on display may include optical information provided from the tool, sensor and coordinate information from sensors, as well as vital patient statistics, such as respiration, heart rate, and/or pulse. The console 16 may be positioned and tilted to allow a physician to access the console from the side of the column 14 opposite carriage 17. From this position, the physician may view the console 16, robotic arms 12, and patient while operating the console 16 from behind the cart 11. As shown, the console 16 also includes a handle 27 to assist with maneuvering and stabilizing cart 11.

FIG. 3 illustrates an embodiment of a robotically-enabled system 10 arranged for ureteroscopy. In a ureteroscopic procedure, the cart 11 may be positioned to deliver a ureteroscope 32, a procedure-specific endoscope designed to traverse a patient's urethra and ureter, to the lower abdominal area of the patient. In a ureteroscopy, it may be desirable for the ureteroscope 32 to be directly aligned with the patient's urethra to reduce friction and forces on the sensitive anatomy in the area. As shown, the cart 11 may be aligned at the foot of the table to allow the robotic arms 12 to position the ureteroscope 32 for direct linear access to the patient's urethra. From the foot of the table, the robotic arms 12 may insert the ureteroscope 32 along the virtual rail 33 directly into the patient's lower abdomen through the urethra.

After insertion into the urethra, using similar control techniques as in bronchoscopy, the ureteroscope 32 may be navigated into the bladder, ureters, and/or kidneys for diagnostic and/or therapeutic applications. For example, the ureteroscope 32 may be directed into the ureter and kidneys to break up kidney stone build up using a laser or ultrasonic lithotripsy device deployed down the working channel of the ureteroscope 32. After lithotripsy is complete, the resulting stone fragments may be removed using baskets deployed down the ureteroscope 32.

FIG. 4 illustrates an embodiment of a robotically-enabled system similarly arranged for a vascular procedure. In a vascular procedure, the system 10 may be configured such that the cart 11 may deliver a medical instrument 34, such as a steerable catheter, to an access point in the femoral artery in the patient's leg. The femoral artery presents both a larger diameter for navigation as well as a relatively less circuitous and tortuous path to the patient's heart, which simplifies navigation. As in a ureteroscopic procedure, the cart 11 may be positioned towards the patient's legs and lower abdomen to allow the robotic arms 12 to provide a virtual rail 35 with direct linear access to the femoral artery access point in the patient's thigh/hip region. After insertion into the artery, the medical instrument 34 may be directed and inserted by translating the instrument drivers 28. Alternatively, the cart may be positioned around the patient's upper abdomen in order to reach alternative vascular access points, such as, for example, the carotid and brachial arteries near the shoulder and wrist.

B. Robotic System—Table.

Embodiments of the robotically-enabled medical system may also incorporate the patient's table. Incorporation of the table reduces the amount of capital equipment within the operating room by removing the cart, which allows greater access to the patient. FIG. 5 illustrates an embodiment of such a robotically-enabled system arranged for a bronchoscopy procedure. System 36 includes a support structure or column 37 for supporting platform 38 (shown as a “table” or “bed”) over the floor. Much like in the cart-based systems, the end effectors of the robotic arms 39 of the system 36 comprise instrument drivers 42 that are designed to manipulate an elongated medical instrument, such as a bronchoscope 40 in FIG. 5 , through or along a virtual rail 41 formed from the linear alignment of the instrument drivers 42. In practice, a C-arm for providing fluoroscopic imaging may be positioned over the patient's upper abdominal area by placing the emitter and detector around table 38.

FIG. 6 provides an alternative view of the system 36 without the patient and medical instrument for discussion purposes. As shown, the column 37 may include one or more carriages 43 shown as ring-shaped in the system 36, from which the one or more robotic arms 39 may be based. The carriages 43 may translate along a vertical column interface 44 that runs the length of the column 37 to provide different vantage points from which the robotic arms 39 may be positioned to reach the patient. The carriage(s) 43 may rotate around the column 37 using a mechanical motor positioned within the column 37 to allow the robotic arms 39 to have access to multiples sides of the table 38, such as, for example, both sides of the patient. In embodiments with multiple carriages, the carriages may be individually positioned on the column and may translate and/or rotate independent of the other carriages. While carriages 43 need not surround the column 37 or even be circular, the ring-shape as shown facilitates rotation of the carriages 43 around the column 37 while maintaining structural balance. Rotation and translation of the carriages 43 allows the system to align the medical instruments, such as endoscopes and laparoscopes, into different access points on the patient. In other embodiments (not shown), the system 36 can include a patient table or bed with adjustable arm supports in the form of bars or rails extending alongside it. One or more robotic arms 39 (e.g., via a shoulder with an elbow joint) can be attached to the adjustable arm supports, which can be vertically adjusted. By providing vertical adjustment, the robotic arms 39 are advantageously capable of being stowed compactly beneath the patient table or bed, and subsequently raised during a procedure.

The arms 39 may be mounted on the carriages through a set of arm mounts 45 comprising a series of joints that may individually rotate and/or telescopically extend to provide additional configurability to the robotic arms 39. Additionally, the arm mounts 45 may be positioned on the carriages 43 such that, when the carriages 43 are appropriately rotated, the arm mounts 45 may be positioned on either the same side of table 38 (as shown in FIG. 6 ), on opposite sides of table 38 (as shown in FIG. 9 ), or on adjacent sides of the table 38 (not shown).

The column 37 structurally provides support for the table 38, and a path for vertical translation of the carriages. Internally, the column 37 may be equipped with lead screws for guiding vertical translation of the carriages, and motors to mechanize the translation of said carriages based the lead screws. The column 37 may also convey power and control signals to the carriage 43 and robotic arms 39 mounted thereon.

The table base 46 serves a similar function as the cart base 15 in cart 11 shown in FIG. 2 , housing heavier components to balance the table/bed 38, the column 37, the carriages 43, and the robotic arms 39. The table base 46 may also incorporate rigid casters to provide stability during procedures. Deployed from the bottom of the table base 46, the casters may extend in opposite directions on both sides of the base 46 and retract when the system 36 needs to be moved.

Continuing with FIG. 6 , the system 36 may also include a tower (not shown) that divides the functionality of system 36 between table and tower to reduce the form factor and bulk of the table. As in earlier disclosed embodiments, the tower may provide a variety of support functionalities to table, such as processing, computing, and control capabilities, power, fluidics, and/or optical and sensor processing. The tower may also be movable to be positioned away from the patient to improve physician access and de-clutter the operating room. Additionally, placing components in the tower allows for more storage space in the table base for potential stowage of the robotic arms. The tower may also include a master controller or console that provides both a user interface for user input, such as keyboard and/or pendant, as well as a display screen (or touchscreen) for pre-operative and intra-operative information, such as real-time imaging, navigation, and tracking information. In some embodiments, the tower may also contain holders for gas tanks to be used for insufflation.

In some embodiments, a table base may stow and store the robotic arms when not in use. FIG. 7 illustrates a system 47 that stows robotic arms in an embodiment of the table-based system. In system 47, carriages 48 may be vertically translated into base 49 to stow robotic arms 50, arm mounts 51, and the carriages 48 within the base 49. Base covers 52 may be translated and retracted open to deploy the carriages 48, arm mounts 51, and arms 50 around column 53, and closed to stow to protect them when not in use. The base covers 52 may be sealed with a membrane 54 along the edges of its opening to prevent dirt and fluid ingress when closed.

FIG. 8 illustrates an embodiment of a robotically-enabled table-based system configured for a ureteroscopy procedure. In a ureteroscopy, the table 38 may include a swivel portion 55 for positioning a patient off-angle from the column 37 and table base 46. The swivel portion 55 may rotate or pivot around a pivot point (e.g., located below the patient's head) in order to position the bottom portion of the swivel portion 55 away from the column 37. For example, the pivoting of the swivel portion 55 allows a C-arm (not shown) to be positioned over the patient's lower abdomen without competing for space with the column (not shown) below table 38. By rotating the carriage 35 (not shown) around the column 37, the robotic arms 39 may directly insert a ureteroscope 56 along a virtual rail 57 into the patient's groin area to reach the urethra. In a ureteroscopy, stirrups 58 may also be fixed to the swivel portion 55 of the table 38 to support the position of the patient's legs during the procedure and allow clear access to the patient's groin area.

In a laparoscopic procedure, through small incision(s) in the patient's abdominal wall, minimally invasive instruments may be inserted into the patient's anatomy. In some embodiments, the minimally invasive instruments comprise an elongated rigid member, such as a shaft, which is used to access anatomy within the patient. After inflation of the patient's abdominal cavity, the instruments may be directed to perform surgical or medical tasks, such as grasping, cutting, ablating, suturing, etc. In some embodiments, the instruments can comprise a scope, such as a laparoscope. FIG. 9 illustrates an embodiment of a robotically-enabled table-based system configured for a laparoscopic procedure. As shown in FIG. 9 , the carriages 43 of the system 36 may be rotated and vertically adjusted to position pairs of the robotic arms 39 on opposite sides of the table 38, such that instrument 59 may be positioned using the arm mounts 45 to be passed through minimal incisions on both sides of the patient to reach his/her abdominal cavity.

To accommodate laparoscopic procedures, the robotically-enabled table system may also tilt the platform to a desired angle. FIG. 10 illustrates an embodiment of the robotically-enabled medical system with pitch or tilt adjustment. As shown in FIG. 10 , the system 36 may accommodate tilt of the table 38 to position one portion of the table at a greater distance from the floor than the other. Additionally, the arm mounts 45 may rotate to match the tilt such that the arms 39 maintain the same planar relationship with table 38. To accommodate steeper angles, the column 37 may also include telescoping portions 60 that allow vertical extension of column 37 to keep the table 38 from touching the floor or colliding with base 46.

FIG. 11 provides a detailed illustration of the interface between the table 38 and the column 37. Pitch rotation mechanism 61 may be configured to alter the pitch angle of the table 38 relative to the column 37 in multiple degrees of freedom. The pitch rotation mechanism 61 may be enabled by the positioning of orthogonal axes 1, 2 at the column-table interface, each axis actuated by a separate motor 3, 4 responsive to an electrical pitch angle command. Rotation along one screw 5 would enable tilt adjustments in one axis 1, while rotation along the other screw 6 would enable tilt adjustments along the other axis 2. In some embodiments, a ball joint can be used to alter the pitch angle of the table 38 relative to the column 37 in multiple degrees of freedom.

For example, pitch adjustments are particularly useful when trying to position the table in a Trendelenburg position, i.e., position the patient's lower abdomen at a higher position from the floor than the patient's lower abdomen, for lower abdominal surgery. The Trendelenburg position causes the patient's internal organs to slide towards his/her upper abdomen through the force of gravity, clearing out the abdominal cavity for minimally invasive tools to enter and perform lower abdominal surgical or medical procedures, such as laparoscopic prostatectomy.

FIGS. 12 and 13 illustrate isometric and end views of an alternative embodiment of a table-based surgical robotics system 100. The surgical robotics system 100 includes one or more adjustable arm supports 105 that can be configured to support one or more robotic arms (see, for example, FIG. 14 ) relative to a table 101. In the illustrated embodiment, a single adjustable arm support 105 is shown, though an additional arm support can be provided on an opposite side of the table 101. The adjustable arm support 105 can be configured so that it can move relative to the table 101 to adjust and/or vary the position of the adjustable arm support 105 and/or any robotic arms mounted thereto relative to the table 101. For example, the adjustable arm support 105 may be adjusted one or more degrees of freedom relative to the table 101. The adjustable arm support 105 provides high versatility to the system 100, including the ability to easily stow the one or more adjustable arm supports 105 and any robotics arms attached thereto beneath the table 101. The adjustable arm support 105 can be elevated from the stowed position to a position below an upper surface of the table 101. In other embodiments, the adjustable arm support 105 can be elevated from the stowed position to a position above an upper surface of the table 101.

The adjustable arm support 105 can provide several degrees of freedom, including lift, lateral translation, tilt, etc. In the illustrated embodiment of FIGS. 12 and 13 , the arm support 105 is configured with four degrees of freedom, which are illustrated with arrows in FIG. 12 . A first degree of freedom allows for adjustment of the adjustable arm support 105 in the z-direction (“Z-lift”). For example, the adjustable arm support 105 can include a carriage 109 configured to move up or down along or relative to a column 102 supporting the table 101. A second degree of freedom can allow the adjustable arm support 105 to tilt. For example, the adjustable arm support 105 can include a rotary joint, which can allow the adjustable arm support 105 to be aligned with the bed in a Trendelenburg position. A third degree of freedom can allow the adjustable arm support 105 to “pivot up,” which can be used to adjust a distance between a side of the table 101 and the adjustable arm support 105. A fourth degree of freedom can permit translation of the adjustable arm support 105 along a longitudinal length of the table.

The surgical robotics system 100 in FIGS. 12 and 13 can comprise a table supported by a column 102 that is mounted to a base 103. The base 103 and the column 102 support the table 101 relative to a support surface. A floor axis 131 and a support axis 133 are shown in FIG. 13 .

The adjustable arm support 105 can be mounted to the column 102. In other embodiments, the arm support 105 can be mounted to the table 101 or base 103. The adjustable arm support 105 can include a carriage 109, a bar or rail connector 111 and a bar or rail 107. In some embodiments, one or more robotic arms mounted to the rail 107 can translate and move relative to one another.

The carriage 109 can be attached to the column 102 by a first joint 113, which allows the carriage 109 to move relative to the column 102 (e.g., such as up and down a first or vertical axis 123). The first joint 113 can provide the first degree of freedom (Z-lift) to the adjustable arm support 105. The adjustable arm support 105 can include a second joint 115, which provides the second degree of freedom (tilt) for the adjustable arm support 105. The adjustable arm support 105 can include a third joint 117, which can provide the third degree of freedom (“pivot up”) for the adjustable arm support 105. An additional joint 119 (shown in FIG. 13 ) can be provided that mechanically constrains the third joint 117 to maintain an orientation of the rail 107 as the rail connector 111 is rotated about a third axis 127. The adjustable arm support 105 can include a fourth joint 121, which can provide a fourth degree of freedom (translation) for the adjustable arm support 105 along a fourth axis 129.

FIG. 14 illustrates an end view of the surgical robotics system 140A with two adjustable arm supports 105A, 105B mounted on opposite sides of a table 101. A first robotic arm 142A is attached to the bar or rail 107A of the first adjustable arm support 105B. The first robotic arm 142A includes a base 144A attached to the rail 107A. The distal end of the first robotic arm 142A includes an instrument drive mechanism 146A that can attach to one or more robotic medical instruments or tools. Similarly, the second robotic arm 142B includes a base 144B attached to the rail 107B. The distal end of the second robotic arm 142B includes an instrument drive mechanism 146B. The instrument drive mechanism 146B can be configured to attach to one or more robotic medical instruments or tools.

In some embodiments, one or more of the robotic arms 142A, 142B comprises an arm with seven or more degrees of freedom. In some embodiments, one or more of the robotic arms 142A, 142B can include eight degrees of freedom, including an insertion axis (1-degree of freedom including insertion), a wrist (3-degrees of freedom including wrist pitch, yaw and roll), an elbow (1-degree of freedom including elbow pitch), a shoulder (2-degrees of freedom including shoulder pitch and yaw), and base 144A, 144B (1-degree of freedom including translation). In some embodiments, the insertion degree of freedom can be provided by the robotic arm 142A, 142B, while in other embodiments, the instrument itself provides insertion via an instrument-based insertion architecture.

C. Instrument Driver & Interface.

The end effectors of the system's robotic arms comprise (i) an instrument driver (alternatively referred to as “instrument drive mechanism” or “instrument device manipulator”) that incorporate electro-mechanical means for actuating the medical instrument and (ii) a removable or detachable medical instrument, which may be devoid of any electro-mechanical components, such as motors. This dichotomy may be driven by the need to sterilize medical instruments used in medical procedures, and the inability to adequately sterilize expensive capital equipment due to their intricate mechanical assemblies and sensitive electronics. Accordingly, the medical instruments may be designed to be detached, removed, and interchanged from the instrument driver (and thus the system) for individual sterilization or disposal by the physician or the physician's staff. In contrast, the instrument drivers need not be changed or sterilized, and may be draped for protection.

FIG. 15 illustrates an example instrument driver. Positioned at the distal end of a robotic arm, instrument driver 62 comprises of one or more drive units 63 arranged with parallel axes to provide controlled torque to a medical instrument via drive shafts 64. Each drive unit 63 comprises an individual drive shaft 64 for interacting with the instrument, a gear head 65 for converting the motor shaft rotation to a desired torque, a motor 66 for generating the drive torque, an encoder 67 to measure the speed of the motor shaft and provide feedback to the control circuitry, and control circuitry 68 for receiving control signals and actuating the drive unit. Each drive unit 63 being independent controlled and motorized, the instrument driver 62 may provide multiple (e.g., four as shown in FIG. 15 ) independent drive outputs to the medical instrument. In operation, the control circuitry 68 would receive a control signal, transmit a motor signal to the motor 66, compare the resulting motor speed as measured by the encoder 67 with the desired speed, and modulate the motor signal to generate the desired torque.

For procedures that require a sterile environment, the robotic system may incorporate a drive interface, such as a sterile adapter connected to a sterile drape, that sits between the instrument driver and the medical instrument. The chief purpose of the sterile adapter is to transfer angular motion from the drive shafts of the instrument driver to the drive inputs of the instrument while maintaining physical separation, and thus sterility, between the drive shafts and drive inputs. Accordingly, an example sterile adapter may comprise of a series of rotational inputs and outputs intended to be mated with the drive shafts of the instrument driver and drive inputs on the instrument. Connected to the sterile adapter, the sterile drape, comprised of a thin, flexible material such as transparent or translucent plastic, is designed to cover the capital equipment, such as the instrument driver, robotic arm, and cart (in a cart-based system) or table (in a table-based system). Use of the drape would allow the capital equipment to be positioned proximate to the patient while still being located in an area not requiring sterilization (i.e., non-sterile field). On the other side of the sterile drape, the medical instrument may interface with the patient in an area requiring sterilization (i.e., sterile field).

D. Medical Instrument.

FIG. 16 illustrates an example medical instrument with a paired instrument driver. Like other instruments designed for use with a robotic system, medical instrument 70 comprises an elongated shaft 71 (or elongate body) and an instrument base 72. The instrument base 72, also referred to as an “instrument handle” due to its intended design for manual interaction by the physician, may generally comprise rotatable drive inputs 73, e.g., receptacles, pulleys or spools, that are designed to be mated with drive outputs 74 that extend through a drive interface on instrument driver 75 at the distal end of robotic arm 76. When physically connected, latched, and/or coupled, the mated drive inputs 73 of instrument base 72 may share axes of rotation with the drive outputs 74 in the instrument driver 75 to allow the transfer of torque from drive outputs 74 to drive inputs 73. In some embodiments, the drive outputs 74 may comprise splines that are designed to mate with receptacles on the drive inputs 73.

The elongated shaft 71 is designed to be delivered through either an anatomical opening or lumen, e.g., as in endoscopy, or a minimally invasive incision, e.g., as in laparoscopy. The elongated shaft 71 may be either flexible (e.g., having properties similar to an endoscope) or rigid (e.g., having properties similar to a laparoscope) or contain a customized combination of both flexible and rigid portions. When designed for laparoscopy, the distal end of a rigid elongated shaft may be connected to an end effector extending from a jointed wrist formed from a clevis with at least one degree of freedom and a surgical tool or medical instrument, such as, for example, a grasper or scissors, that may be actuated based on force from the tendons as the drive inputs rotate in response to torque received from the drive outputs 74 of the instrument driver 75. When designed for endoscopy, the distal end of a flexible elongated shaft may include a steerable or controllable bending section that may be articulated and bent based on torque received from the drive outputs 74 of the instrument driver 75.

Torque from the instrument driver 75 is transmitted down the elongated shaft 71 using tendons along the shaft 71. These individual tendons, such as pull wires, may be individually anchored to individual drive inputs 73 within the instrument handle 72. From the handle 72, the tendons are directed down one or more pull lumens along the elongated shaft 71 and anchored at the distal portion of the elongated shaft 71, or in the wrist at the distal portion of the elongated shaft. During a surgical procedure, such as a laparoscopic, endoscopic or hybrid procedure, these tendons may be coupled to a distally mounted end effector, such as a wrist, grasper, or scissor. Under such an arrangement, torque exerted on drive inputs 73 would transfer tension to the tendon, thereby causing the end effector to actuate in some way. In some embodiments, during a surgical procedure, the tendon may cause a joint to rotate about an axis, thereby causing the end effector to move in one direction or another. Alternatively, the tendon may be connected to one or more jaws of a grasper at distal end of the elongated shaft 71, where tension from the tendon cause the grasper to close.

In endoscopy, the tendons may be coupled to a bending or articulating section positioned along the elongated shaft 71 (e.g., at the distal end) via adhesive, control ring, or other mechanical fixation. When fixedly attached to the distal end of a bending section, torque exerted on drive inputs 73 would be transmitted down the tendons, causing the softer, bending section (sometimes referred to as the articulable section or region) to bend or articulate. Along the non-bending sections, it may be advantageous to spiral or helix the individual pull lumens that direct the individual tendons along (or inside) the walls of the endoscope shaft to balance the radial forces that result from tension in the pull wires. The angle of the spiraling and/or spacing there between may be altered or engineered for specific purposes, wherein tighter spiraling exhibits lesser shaft compression under load forces, while lower amounts of spiraling results in greater shaft compression under load forces, but also exhibits limits bending. On the other end of the spectrum, the pull lumens may be directed parallel to the longitudinal axis of the elongated shaft 71 to allow for controlled articulation in the desired bending or articulable sections.

In endoscopy, the elongated shaft 71 houses a number of components to assist with the robotic procedure. The shaft may comprise of a working channel for deploying surgical tools (or medical instruments), irrigation, and/or aspiration to the operative region at the distal end of the shaft 71. The shaft 71 may also accommodate wires and/or optical fibers to transfer signals to/from an optical assembly at the distal tip, which may include of an optical camera. The shaft 71 may also accommodate optical fibers to carry light from proximally-located light sources, such as light emitting diodes, to the distal end of the shaft.

At the distal end of the instrument 70, the distal tip may also comprise the opening of a working channel for delivering tools for diagnostic and/or therapy, irrigation, and aspiration to an operative site. The distal tip may also include a port for a camera, such as a fiberscope or a digital camera, to capture images of an internal anatomical space. Relatedly, the distal tip may also include ports for light sources for illuminating the anatomical space when using the camera.

In the example of FIG. 16 , the drive shaft axes, and thus the drive input axes, are orthogonal to the axis of the elongated shaft. This arrangement, however, complicates roll capabilities for the elongated shaft 71. Rolling the elongated shaft 71 along its axis while keeping the drive inputs 73 static results in undesirable tangling of the tendons as they extend off the drive inputs 73 and enter pull lumens within the elongated shaft 71. The resulting entanglement of such tendons may disrupt any control algorithms intended to predict movement of the flexible elongated shaft during an endoscopic procedure.

FIG. 17 illustrates an alternative design for an instrument driver and instrument where the axes of the drive units are parallel to the axis of the elongated shaft of the instrument. As shown, a circular instrument driver 80 comprises four drive units with their drive outputs 81 aligned in parallel at the end of a robotic arm 82. The drive units, and their respective drive outputs 81, are housed in a rotational assembly 83 of the instrument driver 80 that is driven by one of the drive units within the assembly 83. In response to torque provided by the rotational drive unit, the rotational assembly 83 rotates along a circular bearing that connects the rotational assembly 83 to the non-rotational portion 84 of the instrument driver. Power and controls signals may be communicated from the non-rotational portion 84 of the instrument driver 80 to the rotational assembly 83 through electrical contacts may be maintained through rotation by a brushed slip ring connection (not shown). In other embodiments, the rotational assembly 83 may be responsive to a separate drive unit that is integrated into the non-rotatable portion 84, and thus not in parallel to the other drive units. The rotational mechanism 83 allows the instrument driver 80 to rotate the drive units, and their respective drive outputs 81, as a single unit around an instrument driver axis 85.

Like earlier disclosed embodiments, an instrument 86 may comprise an elongated shaft portion 88 and an instrument base 87 (shown with a transparent external skin for discussion purposes) comprising a plurality of drive inputs 89 (such as receptacles, pulleys, and spools) that are configured to receive the drive outputs 81 in the instrument driver 80. Unlike prior disclosed embodiments, instrument shaft 88 extends from the center of instrument base 87 with an axis substantially parallel to the axes of the drive inputs 89, rather than orthogonal as in the design of FIG. 16 .

When coupled to the rotational assembly 83 of the instrument driver 80, the medical instrument 86, comprising instrument base 87 and instrument shaft 88, rotates in combination with the rotational assembly 83 about the instrument driver axis 85. Since the instrument shaft 88 is positioned at the center of instrument base 87, the instrument shaft 88 is coaxial with instrument driver axis 85 when attached. Thus, rotation of the rotational assembly 83 causes the instrument shaft 88 to rotate about its own longitudinal axis. Moreover, as the instrument base 87 rotates with the instrument shaft 88, any tendons connected to the drive inputs 89 in the instrument base 87 are not tangled during rotation. Accordingly, the parallelism of the axes of the drive outputs 81, drive inputs 89, and instrument shaft 88 allows for the shaft rotation without tangling any control tendons.

FIG. 18 illustrates an instrument having an instrument based insertion architecture in accordance with some embodiments. The instrument 150 can be coupled to any of the instrument drivers discussed above. The instrument 150 comprises an elongated shaft 152, an end effector 162 connected to the shaft 152, and a handle 170 coupled to the shaft 152. The elongated shaft 152 comprises a tubular member having a proximal portion 154 and a distal portion 156. The elongated shaft 152 comprises one or more channels or grooves 158 along its outer surface. The grooves 158 are configured to receive one or more wires or cables 180 therethrough. One or more cables 180 thus run along an outer surface of the elongated shaft 152. In other embodiments, cables 180 can also run through the elongated shaft 152. Manipulation of the one or more cables 180 (e.g., via an instrument driver) results in actuation of the end effector 162.

The instrument handle 170, which may also be referred to as an instrument base, may generally comprise an attachment interface 172 having one or more mechanical inputs 174, e.g., receptacles, pulleys or spools, that are designed to be reciprocally mated with one or more torque couplers on an attachment surface of an instrument driver.

In some embodiments, the instrument 150 comprises a series of pulleys or cables that enable the elongated shaft 152 to translate relative to the handle 170. In other words, the instrument 150 itself comprises an instrument-based insertion architecture that accommodates insertion of the instrument, thereby minimizing the reliance on a robot arm to provide insertion of the instrument 150. In other embodiments, a robotic arm can be largely responsible for instrument insertion.

E. Controller.

Any of the robotic systems described herein can include an input device or controller for manipulating an instrument attached to a robotic arm. In some embodiments, the controller can be coupled (e.g., communicatively, electronically, electrically, wirelessly and/or mechanically) with an instrument such that manipulation of the controller causes a corresponding manipulation of the instrument e.g., via master slave control.

FIG. 19 is a perspective view of an embodiment of a controller 182. In the present embodiment, the controller 182 comprises a hybrid controller that can have both impedance and admittance control. In other embodiments, the controller 182 can utilize just impedance or passive control. In other embodiments, the controller 182 can utilize just admittance control. By being a hybrid controller, the controller 182 advantageously can have a lower perceived inertia while in use.

In the illustrated embodiment, the controller 182 is configured to allow manipulation of two medical instruments, and includes two handles 184. Each of the handles 184 is connected to a gimbal 186. Each gimbal 186 is connected to a positioning platform 188.

As shown in FIG. 19 , each positioning platform 188 includes a SCARA arm (selective compliance assembly robot arm) 198 coupled to a column 194 by a prismatic joint 196. The prismatic joints 196 are configured to translate along the column 194 (e.g., along rails 197) to allow each of the handles 184 to be translated in the z-direction, providing a first degree of freedom. The SCARA arm 198 is configured to allow motion of the handle 184 in an x-y plane, providing two additional degrees of freedom.

In some embodiments, one or more load cells are positioned in the controller. For example, in some embodiments, a load cell (not shown) is positioned in the body of each of the gimbals 186. By providing a load cell, portions of the controller 182 are capable of operating under admittance control, thereby advantageously reducing the perceived inertia of the controller while in use. In some embodiments, the positioning platform 188 is configured for admittance control, while the gimbal 186 is configured for impedance control. In other embodiments, the gimbal 186 is configured for admittance control, while the positioning platform 188 is configured for impedance control. Accordingly, for some embodiments, the translational or positional degrees of freedom of the positioning platform 188 can rely on admittance control, while the rotational degrees of freedom of the gimbal 186 rely on impedance control.

F. Navigation and Control.

Traditional endoscopy may involve the use of fluoroscopy (e.g., as may be delivered through a C-arm) and other forms of radiation-based imaging modalities to provide endoluminal guidance to an operator physician. In contrast, the robotic systems contemplated by this disclosure can provide for non-radiation-based navigational and localization means to reduce physician exposure to radiation and reduce the amount of equipment within the operating room. As used herein, the term “localization” may refer to determining and/or monitoring the position of objects in a reference coordinate system. Technologies such as pre-operative mapping, computer vision, real-time EM tracking, and robot command data may be used individually or in combination to achieve a radiation-free operating environment. In other cases, where radiation-based imaging modalities are still used, the pre-operative mapping, computer vision, real-time EM tracking, and robot command data may be used individually or in combination to improve upon the information obtained solely through radiation-based imaging modalities.

FIG. 20 is a block diagram illustrating a localization system 90 that estimates a location of one or more elements of the robotic system, such as the location of the instrument, in accordance to an example embodiment. The localization system 90 may be a set of one or more computer devices configured to execute one or more instructions. The computer devices may be embodied by a processor (or processors) and computer-readable memory in one or more components discussed above. By way of example and not limitation, the computer devices may be in the tower 30 shown in FIG. 1 , the cart shown in FIGS. 1-4 , the beds shown in FIGS. 5-14 , etc.

As shown in FIG. 20 , the localization system 90 may include a localization module 95 that processes input data 91-94 to generate location data 96 for the distal tip of a medical instrument. The location data 96 may be data or logic that represents a location and/or orientation of the distal end of the instrument relative to a frame of reference. The frame of reference can be a frame of reference relative to the anatomy of the patient or to a known object, such as an EM field generator (see discussion below for the EM field generator).

The various input data 91-94 are now described in greater detail. Pre-operative mapping may be accomplished through the use of the collection of low dose CT scans. Pre-operative CT scans are reconstructed into three-dimensional images, which are visualized, e.g. as “slices” of a cutaway view of the patient's internal anatomy. When analyzed in the aggregate, image-based models for anatomical cavities, spaces and structures of the patient's anatomy, such as a patient lung network, may be generated. Techniques such as center-line geometry may be determined and approximated from the CT images to develop a three-dimensional volume of the patient's anatomy, referred to as model data 91 (also referred to as “preoperative model data” when generated using only preoperative CT scans). The use of center-line geometry is discussed in U.S. patent application Ser. No. 14/523,760, the contents of which are herein incorporated in its entirety. Network topological models may also be derived from the CT-images, and are particularly appropriate for bronchoscopy.

In some embodiments, the instrument may be equipped with a camera to provide vision data 92. The localization module 95 may process the vision data to enable one or more vision-based location tracking. For example, the preoperative model data may be used in conjunction with the vision data 92 to enable computer vision-based tracking of the medical instrument (e.g., an endoscope or an instrument advance through a working channel of the endoscope). For example, using the preoperative model data 91, the robotic system may generate a library of expected endoscopic images from the model based on the expected path of travel of the endoscope, each image linked to a location within the model. Intra-operatively, this library may be referenced by the robotic system in order to compare real-time images captured at the camera (e.g., a camera at a distal end of the endoscope) to those in the image library to assist localization.

Other computer vision-based tracking techniques use feature tracking to determine motion of the camera, and thus the endoscope. Some features of the localization module 95 may identify circular geometries in the preoperative model data 91 that correspond to anatomical lumens and track the change of those geometries to determine which anatomical lumen was selected, as well as the relative rotational and/or translational motion of the camera. Use of a topological map may further enhance vision-based algorithms or techniques.

Optical flow, another computer vision-based technique, may analyze the displacement and translation of image pixels in a video sequence in the vision data 92 to infer camera movement. Examples of optical flow techniques may include motion detection, object segmentation calculations, luminance, motion compensated encoding, stereo disparity measurement, etc. Through the comparison of multiple frames over multiple iterations, movement and location of the camera (and thus the endoscope) may be determined.

The localization module 95 may use real-time EM tracking to generate a real-time location of the endoscope in a global coordinate system that may be registered to the patient's anatomy, represented by the preoperative model. In EM tracking, an EM sensor (or tracker) comprising of one or more sensor coils embedded in one or more locations and orientations in a medical instrument (e.g., an endoscopic tool) measures the variation in the EM field created by one or more static EM field generators positioned at a known location. The location information detected by the EM sensors is stored as EM data 93. The EM field generator (or transmitter), may be placed close to the patient to create a low intensity magnetic field that the embedded sensor may detect. The magnetic field induces small currents in the sensor coils of the EM sensor, which may be analyzed to determine the distance and angle between the EM sensor and the EM field generator. These distances and orientations may be intra-operatively “registered” to the patient anatomy (e.g., the preoperative model) in order to determine the geometric transformation that aligns a single location in the coordinate system with a position in the pre-operative model of the patient's anatomy. Once registered, an embedded EM tracker in one or more positions of the medical instrument (e.g., the distal tip of an endoscope) may provide real-time indications of the progression of the medical instrument through the patient's anatomy.

Robotic command and kinematics data 94 may also be used by the localization module 95 to provide localization data 96 for the robotic system. Device pitch and yaw resulting from articulation commands may be determined during pre-operative calibration. Intra-operatively, these calibration measurements may be used in combination with known insertion depth information to estimate the position of the instrument. Alternatively, these calculations may be analyzed in combination with EM, vision, and/or topological modeling to estimate the position of the medical instrument within the network.

As FIG. 20 shows, a number of other input data can be used by the localization module 95. For example, although not shown in FIG. 20 , an instrument utilizing shape-sensing fiber can provide shape data that the localization module 95 can use to determine the location and shape of the instrument.

The localization module 95 may use the input data 91-94 in combination(s). In some cases, such a combination may use a probabilistic approach where the localization module 95 assigns a confidence weight to the location determined from each of the input data 91-94. Thus, where the EM data may not be reliable (as may be the case where there is EM interference) the confidence of the location determined by the EM data 93 can be decrease and the localization module 95 may rely more heavily on the vision data 92 and/or the robotic command and kinematics data 94.

As discussed above, the robotic systems discussed herein may be designed to incorporate a combination of one or more of the technologies above. The robotic system's computer-based control system, based in the tower, bed and/or cart, may store computer program instructions, for example, within a non-transitory computer-readable storage medium such as a persistent magnetic storage drive, solid state drive, or the like, that, upon execution, cause the system to receive and analyze sensor data and user commands, generate control signals throughout the system, and display the navigational and localization data, such as the position of the instrument within the global coordinate system, anatomical map, etc.

2. Introduction to Articulating Medical Instruments

Embodiments of the disclosure relate to systems and techniques for articulating medical instruments. FIG. 21 illustrates an example embodiment of a medical instrument 200 in accordance with aspects of this disclosure. In the embodiment illustrated in FIG. 21 , the medical instrument 200 includes a shaft 205, a handle 210, and an end effector 215. The instrument 200 can be coupled to any of the instrument drivers discussed above. One or more cables (not illustrated) can run along an outer surface of the shaft 205 and/or one or more cables can also run through the elongated shaft 205. Manipulation of the one or more cables (e.g., via an instrument driver) results in actuation of the end effector 215.

The handle 210, which may also be referred to as an instrument base, may generally comprise an attachment interface having one or more mechanical inputs, e.g., receptacles, pulleys or spools, that are designed to be reciprocally mated with one or more torque couplers on an attachment surface of an instrument driver.

Depending on the implementation of the particular instrument 200, the end effector 215 may be embodied to perform one or more different medical and/or surgical tasks, which can be effectuated via tensioning the one or more cables. In some embodiments, the instrument 200 comprises a series of pulleys to which the one or more cables can be operatively coupled that enable the shaft 205 to translate relative to the handle 210.

In some embodiments, the instrument 200 may include an end effector 215 adapted to transect and/or seal tissue. FIG. 22A and FIG. 22B illustrate an example embodiment wherein the end effector 215 is configured to function as a medical stapler in accordance with aspects of this disclosure. In particular, FIG. 22A illustrates the end effector 215 in an open position and FIG. 22B illustrates the end effector 215 in a closed position. As shown in FIGS. 22A and 22B, the end effector 215 in the illustrated embodiment includes a lower jaw 310, and upper jaw 315, and a firing mechanism 320. One or more grooves (not illustrated) may be formed in the upper jaw 315. Further, the lower jaw 310 (also referred to as a cartridge jaw) may include a lower jaw slot 330 and the upper jaw 315 may include an upper jaw slot 335. The firing mechanism 320 may include a tab and/or an I-beam in certain implementations as will be described in more detail below. In certain embodiments, the firing mechanism 320 is configured to interact with a magazine (not illustrated) housing a plurality of staples (not illustrated) to drive the staples into tissue. In some embodiments, the firing mechanism can comprise a cantilevered member or push block.

With reference to FIG. 22A, the firing mechanism 320 may be located at a proximal end of the end effector 215 when the end effector 215 is in an open position. The firing mechanism 320 may be configured to engage with each of the lower jaw slot 330 and the upper jaw slot 335. In embodiments where the firing mechanism 320 comprises an I-beam, the lower jaw slot 330 and the upper jaw slot 335 may be shaped to form tracks along which lower and upper flanges of the I-beam are configured to run. In addition, the tracks of the lower jaw slot 330 and the upper jaw slot 335 may be shaped such that as the I-beam of the firing mechanism is advanced a defined distance from the proximal end of the end effector 215, the I-beam closes the upper jaw 315 towards the lower jaw 310, which may be used to clamp tissue between the upper and lower jaws 315 and 310.

As discussed above, the end effector 215 may be embodied as a medical stapler which can be used to seal and/or transect tissue. As shown in FIG. 22B, once the firing mechanism 320 has advanced transversely along the end effector 215 by more than the defined distance from the proximal end of the end effector 215, the end effector 215 will be clamped into the illustrated closed position. The medical instrument 300 can operate by clamping tissue between the two jaws (e.g., the lower jaw 310 and the upper jaw 315) of the medical instrument 300 and then pushing the firing mechanism 320 transversely along the lower jaw 310 and the upper jaw 315 to both form the staples and transect the tissue. Medical staplers such as the medical instrument 300 can be used, for example, in stomach stapling and/or roux-en-y gastric bypass procedures.

In the illustrated embodiment, the medical instrument 300 can move the upper jaw 315 towards the lower jaw 310 (or vice versa in other embodiments) by advancing the firing mechanism 321 from the proximal end of the two jaws 310 and 315 towards the distal end of the medical instrument 300. In more detail, the firing mechanism 321 can be coupled to and engage with the lower jaw slot 330 and the upper jaw slot 335 such that the upper jaw 315 is actuated towards the lower jaw 310 as the firing mechanism 321 is advanced a defined distance from the proximal end of the two jaws 310 and 315. As shown in FIGS. 22A and 22B, the upper jaw slot 335 may be shaped such that as the firing mechanism 321 is advanced along the upper jaw slot 335, the upper jaw 315 is forced to actuate towards the lower jaw 310. In other embodiments, the lower jaw slot 330 may be shaped such that as the firing mechanism 321 is advanced along the lower jaw slot 330, the lower jaw 310 is forced to actuate towards the upper jaw 315.

Once the firing mechanism 321 has been advanced by the defined distance, thereby clamping the upper jaw 315 to the lower jaw 310 with the tissue therebetween, the firing mechanism 321 can be further advanced to perform resection of the tissue. For example, the firing mechanism 321 may comprise a tab housing a blade or other cutting surface configured to resect tissue as the firing mechanism 321 is pushed towards the distal end of the upper jaw 315 and the lower jaw 310. In addition, the firing mechanism 321 may further be configured to interact with the magazine 323 to drive staples housed in the magazine 323 into the tissue. The staples may pierce the tissue and be forced into the one or more grooves 325 of the upper jaw 315, which may bend and redirect the staples back into the tissue.

In some embodiments, the medical instrument 300 may have a wrist configured to be articulated in 1 degree-of-freedom (DOF). For certain medical procedures, for example, robotically controlled laparoscopic procedures, it is desirable to have a 2-DOF wrist. However, there may be design challenges associated with a 2-DOF wrist for a medical stapler which may not be present in a 1 DOF wrist. For example, it can be difficult to route the amount of force required to provide a sufficient clamping force to the jaws through the 2-DOF wrist. In addition, it can be difficult to provide control of the 2-DOF wrist (e.g., provide pitch and yaw DOF), while also independently controlling the stapler and firing mechanism separately from the 2-DOF movement of the wrist. Furthermore, staplers, whether manual or robotic, are often designed to be single-use (e.g., disposable), which can increase the costs associated with the staplers. Lastly, it can be difficult to design a medical stapler to have a low-profile, which can improve the maneuverability of the stapler in constricted spaces.

A. Medical Instrument—Cable-Driven Firing Mechanism.

FIGS. 23A and 23B illustrate views of an example embodiment of a cable-driven medical instrument 400 including an articulating wrist 405 in accordance with aspects of this disclosure. In particular, the medical instrument 400 includes the wrist 405 and a lower jaw 420 (e.g., a lower jaw as illustrated in the figure). The wrist 405 includes a proximal clevis 410 and a distal clevis 415. The medical instrument 400 further includes a firing mechanism 430 housed in the lower jaw 420. As will be explained below, the firing mechanism 430 is configured to be advanced through the lower jaw 420 so as to drive certain components in the cartridge. In some embodiments, the firing mechanism 430 may be in the form of a beam, such as an I-beam as illustrated in FIGS. 23A and 23B, configured to be driven along the lower jaw 420. The I-beam may comprise an upper flange 431 that can interact with the anvil of the upper jaw as described below and a lower flange 433 that can interact with the lower jaw 420.

Although not illustrated, the medical instrument 400 may further comprise an upper jaw which can form an anvil (e.g., as shown in the upper jaw 315 illustrated in FIGS. 22A and 22B), configured to be actuated via movement of the firing mechanism 430 to clamp tissue between the upper jaw and the lower jaw 420. Thus, the instrument 400 may include an end effector comprising a lower jaw 420 and an upper jaw (e.g., including the anvil) and a firing mechanism 430. The firing mechanism 430 can be configured to clamp the anvil to the lower jaw 420 and transect and seal tissue by forming staples in the tissue in a manner similar to that discussed above in connection with FIGS. 22A and 22B. Thus, the firing mechanism 430 may further comprise a cutting mechanism (e.g., a blade or other cutting surface) configured to transect tissue as the firing mechanism 430 is advanced towards the distal end of the lower jaw 420. In other embodiments, the firing mechanism 430 is coupled to a separate cutting mechanism that is configured to be advanced by the firing mechanism 430. The firing mechanism 430 may be moveable along an axis of the end effector (e.g., the lower jaw 420) during actuation of the firing mechanism 430. In certain embodiments, the firing mechanism 430 may be configured to interact with a magazine housing the staples to drive the staples into the tissue. The magazine (not illustrated) may be housed in the lower jaw 420.

The instrument 400 of FIGS. 23A and 23B is configured to drive the firing mechanism 430 via one or more cables. Specifically, to provide 2 DOF movement of the wrist 405 and control actuation of the firing mechanism 430, the instrument 400 further comprises one or more cables 435 configured to pull the firing mechanism 430 forward towards the distal end of the lower jaw 420, one or more cables 440 configured to pull the firing mechanism backward towards the proximal end of the lower jaw 420, and a plurality of pulleys 425, 450, 451, 453, and 455 configured to route the cables 435 and 440 through the instrument 400. In certain embodiments, the instrument 400 may further include one or more cable redirect surfaces configured to aid in the routing of the cables 435 and 440 through the instrument 400. The instrument 400 also includes one or more cables 445 configured to control the actuation of the wrist 405 in 2 DOF, for example, in the yaw and pitch directions. Thus, the wrist 405 may have at least two degrees of freedom of movement. Specifically, the one or more cables 445 may be configured to drive movement of the proximal clevis 410 and the distal clevis 415. In certain embodiments, the wrist 405 may be configured to be actuated according an N+1 driving system, where N+1 cables are used to provide N DOF of actuation for the wrist 405.

The path traced by the cables 435 and 440 through the instrument 400 can be configured such that actuation (e.g., movement) of the firing mechanism 430 is decoupled from movement of the wrist 405 in the at least two degrees of freedom (e.g., rotation of the wrist 405 in the pitch and yaw directions). Thus, actuation of the firing mechanism (e.g., via movement of the firing mechanism 430 along the end effector) can advantageously be independently controlled from the rotation of the wrist 405 without requiring adjustment to the lengths of the cables 435 and 440.

The medical instrument 400 is configured to use the one or more cables 445 to articulate the wrist 405 in the pitch and/or yaw directions and the cables 435 and 440 routed through the wrist 405 for driving the firing mechanism 430 through a magazine (not illustrated) which houses the staples and is integrated into the lower jaw 420; however, in other embodiments, the cartridge may be a separate element which is removable from the lower jaw 420.

The cable 435 can include two cable segments engaged with the firing mechanism 430 via the pulleys 425 located near the distal end of the lower jaw 420 to pull the firing mechanism 430 forward toward the distal end of the lower jaw 420. Similarly, the cable 440 can include two cable segments engaged with the firing mechanism 430 configured to pull the firing mechanism 430 back away from the distal end of the lower jaw 420 toward the wrist 405. The cable 445 can include a set of two cable segments, which along with at least one additional cable segment, are configured to articulate the wrist 405 in the pitch direction (e.g., around an axis concentric with proximal pulleys 451 of the distal clevis 415) and in the yaw direction (e.g., around an axis concentric with distal pulleys 453 of the distal clevis 415).

In some embodiments, the one or more cables or cable segments 435 configured to pull the firing mechanism 430 forward are larger than the one or more other cables or cable segments 440 and 445. This may advantageously provide capacity for greater force in advancing the firing mechanism 430 during actuation of the firing mechanism 430, which may be required for clamping tissue between the upper jaw and the lower jaw 420 as well as transecting tissue as the firing mechanism 430 is advanced. In some embodiments, the cable 435 configured to pull the firing mechanism 430 forward has a diameter of approximately 0.63 mm for strength, while the other cables 440 and 445 have a diameter of approximately 0.50 mm. In other embodiments, the cables may have different diameters and/or each of the cables 435, 440, and 445 may have substantially the same diameter.

As mentioned above, the lower jaw 420 houses a pair of distal redirect pulleys 425 (also referred to simply as distal pulleys) packaged in the front of the lower jaw 420. The cable segments of cable 435 configured to pull the firing mechanism 430 forward are routed around the two distal redirect pulleys 425. The cable segments of cable 435 can share the pull load requirement and can decouple movement of the firing mechanism 430 from movement of the wrist 405 in the pitch and yaw directions. In some embodiments, the load of the cable segments of the cable 435 associated with pulling the firing mechanism 430 forward may be about 250 N, which can be split across the two cable segments of the cable 435.

FIG. 24 illustrates a close up view of the lower jaw 420 of FIGS. 23A and 23B including a portion of the internal components of the firing mechanism 430 in accordance with aspects of this disclosure. Referring to FIGS. 23A, 23B, and 24 , the cable segments of the cable 435 may be connected around a redirect idler pulley 460 housed in the firing mechanism 430. Here, the term “idler pulley” may refer to a pulley that is not connected to an output drive (e.g., movement of a cable or cable segment around an idler pulley is decoupled from actuation of the end effector).

As the wrist 405 is articulated, the total length of the cable 435 including the cable segments is conserved since as the length of one of the cable segments increases during articulation of the wrist 405, the length of the other cable segment decreases by substantially the same amount. The conservation of the total length of the cable segments of the cable 435 can provide the decoupling between the actuation of the firing mechanism (e.g., movement of the firing mechanism 430 along the end effector) from the articulation of the wrist 405.

Similarly, the cable segments of the cable 440 may be connected around a redirect idler pulley 465 housed in the firing mechanism 430. The total length of the cable segments of the cable 435 is also conserved during articulation of the wrist 405. By balancing out cable length changes in each of the cables 435 and 440, the total cable path lengths are conserved, even during articulated motion of the wrist 405.

FIG. 25 illustrates another example embodiment of a cable-driven medical instrument including an articulating wrist in accordance with aspects of this disclosure. In the embodiment illustrated in FIG. 25 , the firing mechanism 431 does not include the pair of idler pulleys 460 and 465 shown in FIG. 24 . Instead, the cable segments of the cables 435 and 440 can be terminated at the firing mechanism 430 and the cable segments of the cables 435 and 440 are connected around one or more idler pulleys 470 and 475 positioned in a shaft 480 of the instrument 400 coupled to a proximal end the wrist 405. Each of the idler pulleys 470 and 475 may be respectively coupled to proximal cables or cable segments 485 and 490 which can be used to advance and retract the firing mechanism 430. Thus, in some embodiments, the cable segments of the cables 435 configured to pull the firing mechanism 430 forward are coupled to the idler pulleys 470 within the shaft 480, which is in turn connected to a proximal cable 480. Similarly, in some embodiments, the cable segments of the cables 440 configured to pull the firing mechanism backward are coupled to the idler pulleys 475 within the shaft 480, which is in turn connected to a proximal cable 490.

FIG. 26 illustrates yet another example embodiment of a cable-driven medical instrument including an articulating wrist in accordance with aspects of this disclosure. In the embodiment illustrated in FIG. 26 , the distal redirect pulleys 427 may have a reduced size and lower profile than the distal redirect pulleys in the embodiment illustrated in FIGS. 23 and 23B. In some embodiments, the distal redirect pulleys 427 of FIG. 26 may have a diameter between 3.0 mm-5.0 mm, while the distal redirect pulleys 425 of FIGS. 23A and 23B may have a diameter between 5.0 mm-7.0 mm. The use of smaller distal redirect pulleys 427 can allow for the entire run of the cable 435 to be located lower along the lower jaw 420 and to shorten the space taken by the distal redirect pulleys 427, thereby advantageously reducing the profile of the instrument. For certain situations, the larger distal redirect pulleys 425 of FIGS. 23A and 23B may be advantageous, as the larger distal redirect pulleys 425 can introduce relatively less wear on larger cables coupled thereto when compared to the smaller distal redirect pulleys 427 of FIG. 26 .

FIG. 27 illustrates still yet another example embodiment of a cable-driven medical instrument including an articulating wrist in accordance with aspects of this disclosure. In the embodiment illustrated in FIG. 27 , the instrument may include a single retract cable segment 441 coupled to a spring return (not illustrated), which may be located proximal to the wrist 405. By incorporating the spring, the number of cable segments and pulleys required for the wrist and firing mechanism can be reduced, simplifying the design of the instrument.

FIGS. 28 and 29 illustrate a top-down view and an endpoint view of yet another example embodiment of a cable-driven medical instrument including an articulating wrist in accordance with aspects of this disclosure. In this embodiment, the profile of the instrument can be reduced by reducing the distance which separates the cable segments of the cable 440 for pulling the firing mechanism backward from the cable segments of the cable 435 for pulling the firing mechanism forward. In some embodiments, the height of the firing mechanism can be changed in vertical height, thereby affecting the overall height of the end effector. In some embodiments, the cable segments of the cable 440 and/or the associated pulleys can be moved up approximately between 0.5-1.5 mm (e.g., 1.0 mm) and/or down approximately between 1.5-2.5 mm (e.g., 2 mm). In some embodiments, the cable segments of the cable 435 and/or their associated pulleys can be moved up approximately between 0.25-0.75 mm (e.g., 0.5 mm) and/or down approximately between 1.5-2.5 mm (e.g., 2 mm). To move the cable segments of the cable 440 down, the associated pulleys can also be moved down. In some embodiments, the cable segments of the cable 435 can also be moved upward, though this may also be accommodated by an increase in the diameter of the distal redirect pulleys 425.

Advantageously, the above-described embodiments in which the firing mechanism is cable-driven can include a greater range of motion than other devices, which may utilize a single push shaft or lead screw to drive an I-beam. This is because the cables and pulleys provide more flexible driving mechanism and therefore, don't have as much loss in efficiency when transmitting forces as the range of motion in the wrist increases.

B. Medical Instrument—Push Shaft-Driven Firing Mechanism.

In the present embodiment, a surgical stapler is provided with a push shaft-driven firing mechanism. Advantageously, the stapler is designed to provide a unique push shaft mechanism to drive a firing mechanism (e.g., I-beam) through a cartridge that is replaceable, thereby allowing the base or core instrument to be reused multiple times (e.g., 5, 10 or more times).

FIG. 30 illustrates an example embodiment of a push shaft-driven medical instrument 500 including an articulating wrist 505 in accordance with aspects of this disclosure. As shown in FIG. 30 , the instrument 500 includes the wrist 505 and an end effector including a lower jaw 525, an upper jaw 530, and a firing mechanism 540 configured to form staples in tissue. The wrist 505 includes a proximal clevis 510, a distal clevis 515, and a lower jaw connector 520 configured to be coupled to the lower jaw 525. In the FIG. 30 embodiment, the lower jaw 525 may comprise an anvil and the upper jaw 530 may comprise a cartridge.

The medical instrument 500 further includes a replaceable cartridge 545 housed in the upper jaw 530 and the firing mechanism includes a firing mechanism 540 housed in the replaceable cartridge 545. In some embodiments, the firing mechanism 540 may include a beam, such as an I-beam as illustrated in FIG. 22 , configured to be driven along the cartridge 545. The upper jaw 530, which is reusable, is capable of receiving the cartridge 545 having a firing mechanism 540 and blade (not illustrated) that can be disposed of upon completion of a procedure. Thus, the end effector (e.g., including the upper jaw 530) is configured to be removably coupled with the cartridge 545.

FIG. 31 provides a view of the cartridge 545 of FIG. 30 , separated from the instrument 500 in accordance with aspects of this disclosure. As shown in FIG. 31 , the cartridge 545 includes an upper slot 550 along which the firing mechanism 540 is configured to be advanced during actuation of the firing mechanism. Thus, the upper slot may be configured to receive the firing mechanism. Referring to FIGS. 30 and 31 , the firing mechanism 540 includes one or more engagement surfaces 535 which are configured to be respectively coupled to one or more push shafts 503. The push shafts 503 are configured to push the firing mechanism 540 towards a distal end of the instrument 500. In some embodiments, the push shafts 503 may comprise tri-wound cables or laser cut metal. In some embodiments, the push shafts 503 are formed to have compressive strength and lateral flexibility so as to bend along with articulation of the wrist 505 without buckling.

In some embodiments, the instrument comprises a pair of engagement surfaces 535 and a pair of push shafts 503. In some embodiments, the firing mechanism may comprise a pair of cup members 535 coupled to the firing mechanism 540, and the engagement surfaces may be formed as part of the cup members 535.

In certain embodiments, the firing mechanism may be formed by the lower jaw 525, the firing mechanism 540, the cup member 535, the upper jaw 530, and the cartridge 545. The firing mechanism may be configured to transect and seal tissue by forming staples in the tissue in a manner similar to that discussed above in connection with FIG. 22 . Thus, the firing mechanism 430 may further comprise tab housing a cutting mechanism (e.g., a blade or other cutting surface) configured to transect tissue as the firing mechanism 540 is advanced towards the distal end of the instrument 500.

Since the cartridge 545 is replaceable, the remaining elements of the instrument 500 can be reused. In some embodiments, the reusable portions of the instrument 500 can be reused 3 or more times, 5 or more times, 8 or more times, or 10 or more times.

As previously mentioned, the instrument 500 includes the pair of push shafts 503 that are capable of engagement with the pair of cup members 535 coupled to the firing mechanism 540 and blade of the disposable cartridge 545. The disposable cartridge 545 includes an upper slot 550 and a lower slot (not shown) through which the firing mechanism 540 and blade can be pushed through. In some embodiments, the disposable cartridge 545 can be snap fitted into the instrument 500 (e.g., into the upper jaw 530).

When the cartridge 545 is snapped into the instrument 500, the push shafts 503 can move forward and engage with the firing mechanism 540. The push shafts 503 may be configured to snap into the firing mechanism 540. In certain embodiments, the connection between the push shafts 503 and the cup members 535 include ball-and-socket joint connections. In other embodiments, the push shafts 503 may fit into an engagement surface formed in the firing mechanism 540 without a snap-fit therebetween. In some embodiments, the engagement surface formed in the firing mechanism 540 is tapered.

In some embodiments, rather than using a pair of push shafts 503, a single push shaft can be used. However, using the two push shafts 503 as shown in FIG. 30 advantageously distributes the pushing force evenly across the firing mechanism 540 and provides a clearance zone in between the two push shafts 503. The use of two push shafts 503 can be used to translate the firing mechanism 540 and blade through a slot formed in the upper jaw 530.

FIG. 32 illustrates another view of the push shaft-driven medical instrument 500 of FIG. 30 in accordance with aspects of this disclosure. Advantageously, the upper jaw 530 includes a wider clearance slot 560 at the end of a slot 555 to allow for the firing mechanism 540 to be removed through the upper jaw 530. FIG. 33 illustrates yet another view of the push shaft-driven medical instrument 500 of FIG. 30 from the bottom in accordance with aspects of this disclosure. As shown in FIG. 33 , the lower jaw 525 includes a slot 565 with a wider clearance slot 570 similar to the clearance slot 560 in the upper jaw 530. The firing mechanism 540 is configured to engage with the slot 555 of the upper jaw 530 and the slot 565 of the lower jaw 525 during actuation of the firing mechanism 540. By having a pair of clearance slots 560 and 570 sized to allow passage of the firing mechanism 540, one in the upper jaw 530 and the other in the lower jaw 525, the firing mechanism 540 and the disposable cartridge 545 can be easily removed without having to return the firing mechanism 540 to its proximal position after actuation of the firing mechanism. That is, since the firing mechanism 540 can pass through both the upper jaw 530 and the lower jaw 525, the firing mechanism 540 can be removed from the distal end of the instrument without being returned to the proximal end of the cartridge 545.

As shown in FIG. 33 , the wrist 505 may include one or more anti-buckling constraints 575 through which the push shafts 503 can be moved through the wrist 505. The anti-buckling constraints 575 may be shaped to constrain each of the push shafts 503 from buckling by providing lateral support to the push shafts 503 as the push shafts 503 are guided through the wrist 505. In some embodiments, the anti-buckling constraints 575 may comprise one or more channels (e.g., the anti-buckling constraints 575 may have a tubular shape) configured to guide and support the push shafts 503 through the wrist 505. Thus, in some embodiments, the anti-buckling constraints 575 can prevent buckling of the push shafts 503.

FIG. 34 illustrates yet another view of the push shaft-driven medical instrument 500 of FIG. 30 without the cartridge installed in accordance with aspects of this disclosure. In particular, FIG. 34 illustrates the clearance slot 560 of the upper jaw 530 and the clearance slot 570 of the lower jaw 525. As previously described, the clearance slots 560 and 570 formed in the upper jaw 530 and the lower jaw 525 enables the cartridge 545 and the firing mechanism 540 (e.g., see FIG. 30 ) to be removed from the instrument 500 without returning the firing mechanism 540 back to the proximal end of the upper jaw 530 (e.g., the initial proximal position of the firing mechanism 540).

In one embodiment, following the translation of the firing mechanism 540 to the distal end of the cartridge 545, removal of the cartridge 545 can include the firing mechanism 540 being pushed through the clearance slot 560 of the upper jaw 530 and falling through the clearance slot 570 of the lower jaw 525. The upper jaw 530 can then be lifted upwards away from the lower jaw 525 to allow the cartridge 545 to be removed from the upper jaw 530.

In some embodiments, the instrument 500 can include a unique firing mechanism including a housing that houses a cutting mechanism or blade that can be automatically retracted into a safe, covered position when the firing mechanism is not being pushed through tissue. FIGS. 35A-35D provide a plurality of views of a firing mechanism 600 which can be included in the push shaft-driven medical instrument 500 in accordance with aspects of this disclosure. In particular, FIG. 35A illustrates a hidden line view of the firing mechanism 600 with a retractable blade 630, FIG. 35B illustrates a hidden line view of the firing mechanism 600 with the retractable blade 630 exposed, FIG. 35C illustrates a perspective view of the firing mechanism 600 with the retractable blade 630 retracted, and FIG. 35D illustrates a perspective view of the firing mechanism 600 with the retractable blade 630 exposed.

The firing mechanism 600 includes a tab 610, a pair of engagement surfaces 605, the retractable blade 630, and a spring 615. Similar to the previously described embodiments, the firing mechanism 600 can be configured to interact with a magazine housing the staples to drive the staples into the tissue. In some embodiments, the firing mechanism 600 may comprise an I-beam. The retractable blade 630 is connected to the engagement surfaces 605 (which may be formed as part of cup members as described above) such that a driving force applied to the engagement surfaces 605 via push shafts is transmitted to the retractable blade 630. In some embodiments, each of the engagement members 605 comprises a ball-and-socket joint and the push shafts are configured to engage the ball-and-socket joints. The retractable blade 630 is further connected to the spring 615 and comprises a slot 625 that is coupled to a pin 620 attached to the tab 610.

The retractable blade 630 is configured to be retracted into the tab 610 as shown in FIGS. 35A and 35C. Specifically, when no force is being exerted on the engagement surfaces 605, the spring 615 is configured to pull the retractable blade 630 into a retracted position in which no portion of the retractable blade 630 is exposed from the tab 610. The pin 620 of the tab 610 together with the slot 625 in the retractable blade 630 may limit the distance the spring 615 is able to pull the retractable blade 630 into the tab 610, maintaining a certain amount of tension in the spring 615 when the retractable blade 630 is in the retracted position.

When force is exerted on the engagement surfaces 605 by the push shafts, the force due to the push shafts may overcome the retaining force of the spring 615, moving the retractable blade 630 out of the tab 610 thereby exposing the retractable blade 630. Thus, as the firing mechanism 600 is pushed through the cartridge via the push shafts, the retractable blade 630 can be exposed from the tab 610 to transect tissue. In other words, the push shafts can be configured to engage the spring 615 to push the retractable blade 630 forward, thereby exposing the retractable blade 630 while translating the firing mechanism 600 along an axis of the end effector.

Although the firing mechanism 600 has been described in connection with a push shaft-driven instrument (e.g., the instrument 500 of FIG. 30 ), the firing mechanism 600 including the retractable blade 630 can also be modified to be used with a cable driven instrument (e.g., the instrument 400 of FIGS. 23A and 23B). Thus, the firing mechanism 600 can be configured to be advanced along an end effector by different types of driving mechanisms (e.g., a push shaft or cable).

Advantageously, certain embodiments of the push shaft-driven instrument provide a convenient way to integrate a retractable blade safely into the firing mechanism. In addition, push shaft-driven embodiments of the instrument provide a good and unique separation point for the cartridge, thereby allowing a greater portion of the instrument to be reused.

3. Implementing Systems and Terminology

Implementations disclosed herein provide systems, methods and apparatus for articulating medical instruments such as a medical stapler including an articulating wrist.

It should be noted that the terms “couple,” “coupling,” “coupled” or other variations of the word couple as used herein may indicate either an indirect connection or a direct connection. For example, if a first component is “coupled” to a second component, the first component may be either indirectly connected to the second component via another component or directly connected to the second component.

The functions for controlling the articulating medical instruments described herein may be stored as one or more instructions on a processor-readable or computer-readable medium. The term “computer-readable medium” refers to any available medium that can be accessed by a computer or processor. By way of example, and not limitation, such a medium may comprise random access memory (RAM), read-only memory (ROM), electrically erasable programmable read-only memory (EEPROM), flash memory, compact disc read-only memory (CD-ROM) or other optical disk storage, magnetic disk storage or other magnetic storage devices, or any other medium that can be used to store desired program code in the form of instructions or data structures and that can be accessed by a computer. It should be noted that a computer-readable medium may be tangible and non-transitory. As used herein, the term “code” may refer to software, instructions, code or data that is/are executable by a computing device or processor.

The methods disclosed herein comprise one or more steps or actions for achieving the described method. The method steps and/or actions may be interchanged with one another without departing from the scope of the claims. In other words, unless a specific order of steps or actions is required for proper operation of the method that is being described, the order and/or use of specific steps and/or actions may be modified without departing from the scope of the claims.

As used herein, the term “plurality” denotes two or more. For example, a plurality of components indicates two or more components. The term “determining” encompasses a wide variety of actions and, therefore, “determining” can include calculating, computing, processing, deriving, investigating, looking up (e.g., looking up in a table, a database or another data structure), ascertaining and the like. Also, “determining” can include receiving (e.g., receiving information), accessing (e.g., accessing data in a memory) and the like. Also, “determining” can include resolving, selecting, choosing, establishing and the like.

The phrase “based on” does not mean “based only on,” unless expressly specified otherwise. In other words, the phrase “based on” describes both “based only on” and “based at least on.”

The previous description of the disclosed implementations is provided to enable any person skilled in the art to make or use the present invention. Various modifications to these implementations will be readily apparent to those skilled in the art, and the generic principles defined herein may be applied to other implementations without departing from the scope of the invention. For example, it will be appreciated that one of ordinary skill in the art will be able to employ a number corresponding alternative and equivalent structural details, such as equivalent ways of fastening, mounting, coupling, or engaging tool components, equivalent mechanisms for producing particular actuation motions, and equivalent mechanisms for delivering electrical energy. Thus, the present invention is not intended to be limited to the implementations shown herein but is to be accorded the widest scope consistent with the principles and novel features disclosed herein. 

What is claimed is:
 1. An instrument, comprising: a wrist having at least two degrees of freedom of movement; an end effector coupled to the wrist, the end effector comprising an upper jaw, a lower jaw, and a firing mechanism, wherein the firing mechanism comprises a tab moveable along an axis of the end effector for advancing a staple into tissue; and one or more cable segments configured to drive motion of the tab, wherein the one or more cable segments are movable along the tab.
 2. The instrument of claim 1, wherein the wrist comprises a proximal clevis and a distal clevis.
 3. The instrument of claim 2, wherein the proximal clevis and distal clevis are cable driven.
 4. The instrument of claim 1, wherein the tab comprises an I-beam.
 5. The instrument of claim 1, further comprising: one or more cable segments configured to pull the tab backward, wherein the one or more cable segments are movable relative to the tab.
 6. The instrument of claim 5, wherein the one or more cable segments configured to pull the tab backward are in contact with to one or more idler pulleys within the tab.
 7. The instrument of claim 5, further comprising: a shaft coupled to a proximal end of the wrist and comprising one or more idler pulleys, wherein the one or more cable segments configured to pull the tab backward are in contact with to the one or more idler pulleys within the shaft.
 8. The instrument of claim 7, wherein the one or more cable segments configured to pull the tab backward terminate at the tab.
 9. The instrument of claim 5, wherein the one or more cable segments configured to pull the tab backward are in contact with to one or more springs.
 10. The instrument of claim 1, wherein the one or more cable segments configured to pull the tab forward are in contact with to a pair of distal pulleys.
 11. The instrument of claim 1, wherein the one or more cable segments configured to pull the tab forward are in contact with to one or more idler pulleys within the tab.
 12. The instrument of claim 1, further comprising: a shaft coupled to a proximal end of the wrist and comprising one or more idler pulleys, wherein the one or more cable segments configured to pull the tab forward are in contact with to the one or more idler pulleys within the shaft.
 13. The instrument of claim 12, wherein the one or more cable segments configured to pull the tab forward terminate at the tab.
 14. The instrument of claim 1, further comprising one or more cable segments configured to articulate the wrist.
 15. An instrument, comprising: a wrist having at least two degrees of freedom of movement; an end effector coupled to the wrist, the end effector comprising an upper jaw, a lower jaw, and a firing mechanism, the firing mechanism comprising a tab, a pair of cup members, and a pair of push shafts, the tab being moveable along an axis of the end effector for driving a staple into tissue, the pair of cup members coupled to the tab, and the pair of push shafts configured to engage with the pair of cup members to push the tab towards a distal end of the instrument.
 16. The instrument of claim 15, wherein the tab is configured to be coupled to a retractable blade. 